Skip to main content

Full text of "United States Navy Medical News Letter Vol. 45 No. 11, 11 June 1965"

See other formats

NAVMED P-3088 


I Medical News Letter 

Vol. 45 

Friday, 11 June 1965 

No. 11 


Anniversary Greetings to the Hospital Corps ii 


"What's New in the Management of Trauma" — Man- 
agement of Gram-Negative Septic Shock 1 


An Unusual Injury Due to the Seat Belt 2 


Indianapolis to Host Joint Occupational Health Con- 
gress and State Medical Meeting 4 

Notice to Senior Medical Students 5 

Metrecal — Serum Iodine 5 

Influenza Vaccine 5 

An Increase in the Employment of Nurses 6 

Correspondence Courses 6 

Angiography — Cotton Fiber Embolization 7 

Well Done— C.G. FMFLANT 7 

In Memoriam 7 


Current Oral Surgical Opinion Concerning the Value of 

Pre-Irradiation Exodontia 8 

A Vexatious Erratic Oral Lesion: Necrotizing Ulcera- 
tive Gingivitis 8 

Dental Support to the Fleet Marine Force 9 

Personnel and Professional Notes 10 



Medical Factors Related to Driving Ability 

How Safe are Health Workers? Health Hazards to 
Health Workers 16 

Accident Hazards of Health Workers 18 


The Manager's Role in Quality Staffing 19 





As Surgeon General of the U. S. Navy, it gives me great 
pleasure on this 67th anniversary of the U. S. Navy Hospi- 
tal Corps, to extend my heartiest congratulations to every 
hospital corpsman throughout the world. 

Today, as in the past, you continue to provide the always 
dedicated service to the sick and injured that has become 
the "Hallmark" of the Hospital Corps. On ships at sea, 
under the sea, in the air, and in foreign lands the world 
over you have repeatedly accepted challenges vital to ac- 
complishing the mission of the Medical Department with ad- 
mirable loyalty and devotion. 

That the Hospital Corps has and continues to rise to the 
Increasing demands and skills required in our ever expand- 
ing medical technology is personally gratifying and a source 
of inspiration to all. What new challenges the future holds 
cannot be predicted; however, I am certain they will be met 
and accomplished with the same enthusiasm and esprit de corps 
that has become the measure of standard in past performance. 

For myself, and on behalf of the Medical Department of the 
Navy - "Well Done" and a Happy Birthday! 

United States Navy 

Vol. 45 

Friday, 11 June 1965 

No. 11 

Rear Admiral Robert B. Brown MC USN 
Surgeon General 

Rear Admiral R. O. Canada MC USN 
Deputy Surgeon General 

Captain F. R. Petiprin MSC USN, Editor 

William A. Kline, Managing Editor 

Contributing Editors 

Aviation Medicine Captain C. E. Wilbur MC USN 

Dental Section Captain C. A. Ostrom DC USN 

Occupational Medicine CDR N. E. Rosenwinkel MC USN 

Preventive Medicine Captain J. W. Millar MC USN 

Radiation Medicine Captain J. H. Schulte MC USN 

Reserve Section Captain C Cummings MC USNR 

Submarine Medicine Captain J. H, Schulte MC USN 

The U.S. Navy Medical News Letter is basically an 
official Medical Department publication inviting the 
attention of officers of the Medical Department of the 
Regular Navy and Naval Reserve to timely up-to-date 
items of official and professional interest relative to 
medicine, dentistry, and allied sciences. The amount 
of information used is only that necessary to inform 
adequately officers of the Medical Department of the 
existence and source of such information. The items 
used are neither intended to be, nor are they, sus- 

ceptible to use by any officer as a substitute for any 
item or article in its original form. All readers of the 
News Letter are urged to obtain the original of those 
items of particular interest to the individual. 

Change of Address 

Please forward changes of address for the News Letter 
to: Commanding Officer, U.S. Naval Medical School, 
National Naval Medical Center, Bethesda, Maryland 
20014, giving full name, rank, corps, and old and new 


FRONT COVER: View taken from the Hospital Pier of the U. S. Naval Hospital, Newport, R. I. Built 
in 1896, this hospital 60 ft. long and 33 ft. wide served until 1913 when it was vacated. In 1917 it was 
reopened to serve as a training school for Pharmacists Mates until closing again in 1923. 

The first section of the present hospital was erected on part of 15.33 acres of farm land purchased from 
the Misses Smith, Hunter and Swindburne. 

This hospital was officially opened on 15 April 1913 with a staff of four medical officers, one dental of- 
ficer, eleven nurses, one pharmacist, twenty-six pharmacists mates and thirty-two civilian employees. The 
first patient census was sixty. 

Nine additional wards were built during World War I and bed capacity increased by 390. There were 
423 patients in the hospital at the end of 1917. Also in 1917 a diphtheria epidemic errupted which was 
beyond the capabilities of the small Newport civilian hospital. The Naval Hospital allotted three tempo- 
rary wards and provided the staff and drugs to care for the sick. 

This hospital also served in the most exemplary manner in the influenza epidemic of 1918; when 1,000 
patients were under treatment: in 1925 when the excursion steamer Mackinak exploded, 130 injured were 
cared for here; in 1954 when the aircraft carrier Bennington suffered an explosion, ninety men were killed 
and eighty-two casualties were brought to the hospital many in serious and critical condition; and again in 
1958 when the tanker Gulf Oil collided with the cargo ship Grahamn between Newport and Jamestown. In- 
jured seamen from both ships were cared for by the hos pital staff. 

The years 1913-1963 saw the hospital grow from a main building and bed capacity of 150 to a World 
War II peak of 42 buildings and 1,492 patients reached on 26 February 1945. — Editor 

The issuance of this publication approved by the Secretary of the Navy on 4 May 1964. 





/. C. Rosenberg, M. D. Ph.D., Department of Surgery, V. of Ky. Medical Center, 

Lexington, Kentucky 

There has been a relative increase in the frequency 
of infection resulting from nonsporulating microor- 
ganisms of fecal origin (Pseudomonas, Proteus, etc.). 
Forty percent of deaths secondary to bactermic in- 
fections are now caused by gram-negative organisms. 
Prior to the antibiotic era, this figure was 9% . (1) 

It is thought that the shock-producing agent in 
gram-negative infections is a polysaccharide-protein- 
lipid complex, known as, "endotoxin", which is a 
component of the cell wall of the micro-organism. 
With autolysis of the bacteria, this toxic substance is 
liberated and sets off a chain reaction terminating in 
shock. (2) Extensive laboratory studies of lethal 
endotoxemia have been carried out and are helpful 
in formulating a rational therapeutic approach to 
gram negative septicemic shock. 

Blood Volume Replacement 

Hypovolemia may be present secondary to blood 
loss, sequestration of fluid in the infected, trauma- 
tized area or due to increased losses resulting from 
fever. Three guides can be used for blood volume 
replacement; the hematocrit, the central venous pres- 
sure and blood volume determinations. The first 
two can readily be followed with a minimal amount 
of equipment and effort. Plasma and saline or 
Hartmann's solution should be given if the hemato- 
crit is high (over 40% ) and the central venous pres- 
sure low (under 10 cm' of water). Otherwise whole 
blood should be used. Blood volume expanders may 
be substituted for plasma. Low-Molecular weight 
dextran (no more than 1000 cc) may be beneficial 
in decreasing "sludging". Mannitol may be used to 
induce a solute diuresis. 


The use of pharmacologic doses of corticosteroids 
(2 to 3 Gm of hydrocortisone daily) during the first 
2 to 3 days following the appearance of shock has 

been demonstrated to be of great benefit clinically 
and experimentally. There is no need to taper the 
dose or utilize maintenance doses of steroids if the 
patient survives. Recent experimental work has in- 
dicated that the adrenal steroid, aldosterone, may 
bind endotoxin and thus ameliorate the effects of 
gram-negative septic shock. 


A constant concomitant of shock is metabolic 
acidosis secondary to poor tissue perfusion and hy- 
poxia. The use of bicarbonate, and occasionally 
THAM, is often required and is discussed elsewhere 
in this series of articles. Tracheostomy and auto- 
matic ventilation may be required if there is evidence 
of respiratory acidosis. The arterial pH, PO a and 
PCQ, are the best guides to therapy in this area. 

Antibiotics and Control of Infection 

Drainage of abscesses, debridement of necrotic 
tissue, exteriorization of intestinal fistulae, etc., 
should be carried out as soon as feasible. Material 
for indentification of the offending organism and its 
antibiotic sensitivity can be obtained at this time or 
by blood cultures. Antibiotics consisting of massive 
doses of penicillin (40 million units intravenously 
daily) and a broad spectrum antibiotic such as 
Chloromycetin (2-4 gm daily) should be started im- 
mediately; before material for culture is obtained. 

Vasopressors- Vasodilators 

Vasoconstrictor drugs should only be used as a 
resuscitative measure when the blood pressure is 
unobtainable and cardiac activity is not evident. Its 
prolonged use may be deleterious, especially with 
regard to renal function. Occasionally, when the 
blood volume is maximally expanded and all else 
fails, small amounts of nasopressor may improve 



peripheral blood flow, as evidenced by an increase 
in urine output. 

A large body of information has recently been ac- 
cumulated to indicate that vasodilators, such as 
dibenzyline, may be beneficial. Adrenergic blockade 
with dibenzyline is available to only a few investiga- 
tors. It holds promise as a therapeutic tool either 
alone or when combined with different types of 
vasoconstricting agents. Its clinical use is still quite 
properly on an investigational basis only. 

Miscellaneous Considerations 

If a high fever is present, hypothermia may control 
the resulting increased metabolic rate. Oxygen 
therapy, including use of hyperbaric chambers, has 
not proven helpful. Although there is some protec- 
tive effect with heparin pre-treatment in experimental 
endotoxin shock, clotting defects are common later 
in the course of the disease and have no role in the 
clinical management of gram-negative shock. As- 
sisted circulation (cardio-pulmonary bypass) has 
been investigated but has also not proven to be 
worthwhile. Splenic extracts which detoxify endo- 
toxin have recently been developed and may prove 

to be a specific means of treating this form of 
shock. (3) 

At the moment the proven keystones in the treat- 
ment of endotoxic or shock of bacterial origin are : 

1. Control of infection — including surgical means. 

2. Specific antibiotic therapy. 

3. Blood volume replacement. 

4. Correction of acidosis. 

Of less definite but suggestive value are : 

1. Large doses of steroids. 

2. Vasodilators with or without vasopressors. 

Of purely theoretic interest and of unproven 
clinical value. 

1. Hypothermic. 

2. Hyperbaric oxygen. 

3. Assisted circulation. 

4. Splenic extracts. 


1. Finland, M. ■ Treatment of Pneumonia and Other Serious Infec- 
tions. New England J Medicine, 263: 207, 1960. 

2. Rosenberg, J. C. et al: Studies on Hemorrhagic and Endotoxin 
Shock in Relation to Vasomotor Changes and Endogenous Circu- 
lating Epinephrine Norepinephrine and Serotonin. Ann Surgery, 
154: 611-628, 1961. 

3. Fine, J., Current Status of the Problem of Traumatic Shock. Surg 
Gyn & Obstet 120: 537, 1965. 



Capt. Stephen H. Tolins, MC, USN 

Throughout the nation people are being urged to 
form the seat belt habit. 1 ' 3 - 5 ' 8 As early as 1953 the 
California Highway Patrol was using seat belts and, 
in 1957, the California Vehicle Code provided for 
the investigation of all motor vehicle accidents in- 
volving personal injury as to the effect, if any, safety 
belts would have had on the accident. Seat belts 
have been the subject of U. S, Public Health Service 
leaflets and Congressional hearings. The Automotive 
Crash Injury Research of Cornell University has for 
years done extensive research on this problem and 
published numerous excellent comprehensive re- 
ports. 3 ' 5 ' 6 

The following case is presented to delineate what 
might be termed a definitive syndrome and not in 
any way to detract from the proven efficiency and 
life-saving capabilities of seat belts. 

From the Surgery Branch, Bureau of Medicine and Surgery, Depart- 
ment of the Navy, Washington 25, D. C. The opinions contained 
herein are those of the author and are not to be construed as official 
or reflecting the view of the Navy Department. 

Case Report 

L. W. F., Hospital #146351, was admitted to the 
U. S. Naval Hospital, Jacksonville, Florida 28 hours 
after having been in an automobile accident, com- 
plaining of cramping abdominal pains. 

The patient had been riding in the seat beside the 
driver of a 1957 Ford station wagon wearing a deck- 
bolted type seat belt. The driver and the three 
passengers in the back had not put on their seat 
belts. While traveling at a speed of 65 miles per 
hour the car missed a turn and went down a hill to 
the right striking a telephone pole with the left front 
area of the car. On impact, the driver was leaning on 
and holding on to the patient in the seat beside him 
and all three passengers in the back were thrown for- 
ward pushing the front seat forward as they did so. 
The patient's seat belt held however, and he states 
that he felt as if it were "cutting me in two." The 
patient suffered two small lacerations of the forehead 


and a bruise across the central portion of the abdo- 
men. He was helped from the car by the other pas- 
sengers, none of whom were in any way injured, and 
sat on the ground until taken by ambulance to a 
nearby dispensary. There, x-rays of the chest and 
abdomen were taken which were reported as being 
negative. The patient was observed there throughout 
the following day and, as his cramps became more 
severe, he was transferred to this hospital. 

During the hours prior to admission, the patient 
had vomited once, the vomitus did not contain blood, 
and there had been no bowel movements. 

The past history revealed only a shell fragment 
wound of the left foot during World War II. The 
systemic review was entirely unrevealing. 

Physical examination on admission revealed the 
temperature 99.2, pulse 88, and blood pressure 130/ 
84. The patient was a medium build, being 5'7" 
and weighing 152 pounds. He was alert and well 
oriented and appeared in acute distress with lower 
abdominal pain. There were sutured lacerations of 
the forehead and scalp and a large area of ecchymo- 
sis over the right iliac crest. The abdomen was 
protuberant with hypoactive bowel sounds and gen- 
eralized tenderness without spasm. The urinalysis 
revealed a trace of albumin, 2-4 RBC, and 20-25 
WBC per high powered field. The blood count on 
admission revealed 11,700 white blood cells with 89 
per cent neutrophiles, the hematocrit 49, and hemo- 
globin 16.4. The amylase was 62. Chest x-ray 
revealed minimal elevation of the left diaphragm 
with some haziness in the region of the costophrenic 
angle. The lung fields were otherwise clear. Lateral 
and upright films of the abdomen revealed consider- 
able gaseous distension of the small bowel, psoas 
markings were sharp bilaterally and there were small 
amounts of gas and feces scattered about the colon. 
In the lateral decubitus with the left side down there 
was some fluid layering out in the left hemithorax. 

On the day of admission a left thoracentesis was 
performed removing a small amount of slightly 
cloudy fluid. With the developing ileus, the patient 
was treated with nasogastric suction and intravenous 
fluids and electrolytes while being closely observed 
for the possibility of a ruptured viscus. On the sec- 
ond post-injury day his vital signs remained approxi- 
mately the same and study of the blood electrolytes 
revealed sodium 130, potassium 4.7, chloride 90, 
C0 2 22, and calcium 10.4. Amylase study done on 
the fluid taken from the left chest revealed a value of 
420 units. Repeat chest x-ray revealed blunting of 
the right costophrenic angle with slight clearing of 

the left. Films of the abdomen still revealed dilated 
loops of small bowel. 

It was felt that the patient had a traumatic pan- 
creatitis and treatment of nasogastric suction and 
parenteral feedings was continued. On the third 
post-trauma day his general condition was unchanged 
while the patient insisted that he felt better. On the 
morning of the fourth post-trauma day the abdomen 
appeared more distended and tense and no bowel 
sounds could be heard. X-ray examination of the 
abdomen again revealed dilated loops of small bowel 
with some gas and fecal material in the large bowel. 
It was felt at this time that the possibility of a 
ruptured duodenum or upper jejunum or extrahepatic 
biliary duct was a very real one and that exploration 
was indicated. 

Under endotracheal anesthesia, through a right 
upper paramedian incision, exploration was per- 
formed. There was a generalized peritonitis present 
with fibrinous adhesions scattered throughout and a 
blowout-type perforation approximately 2 cm. in di- 
ameter on the mesenteric border of the small bowel 
in the upper jejunal region. This was debrided and 
closed in two layers. The duodenal loop was Koch- 
erized and this area and the entire abdomen was 
carefully inspected with no other abnormalities being 
noted. The abdomen was thoroughly irrigated and 
closed in layers using catgut for peritoneum and 
stainless steel wire for the fascia and skin. The pa- 
tient withstood the procedure well and required a 
unit of whole blood as transfusion during the proce- 
dure. His postoperative course was complicated by 
wound infection which yielded E. coli and coagulase 
positive staphylococci sensitive to all antibiotics ex- 
cept penicillin. With proper drainage and antibiotics 
this infection cleared and secondary closure was then 
possible after excision of a sinus tract. On the 62nd 
hospital day the patient was discharged fit for duty. 


This type of injury fortunately is rare; however, 
it does occur. In his discussion of 2,778 accidents 
involving 944 injuries, Garrett s notes one case of 
ruptured pancreas and duodenum. The treating phy- 
sician had noted "the seat belt caused injury, but 
saved the patient's life." Kulowski and Rost i de- 
scribed a case of intermittent partial obstruction of 
the ileum due to adhesions at the site of previous 
mesentery tear caused presumably by a seat belt in 
an auto accident. A questionnaire sent to 19 naval 
hospitals within the United States revealed the oc- 
currence of one case of sigmoid colon rupture due 
to "seat belt injury." 


The recognition of the particular clinical picture 
produced by this type of nonpenetrating blunt ab- 
dominal trauma has been well documented previ- 
ously.' The transient period of shock-like state, 
which is mild in character, followed by gradual ap- 
pearance over several days of symptoms of abdomi- 
nal pain and signs of abdominal rigidity, usually 
ascribed to reflex adynamic ileus or traumatic pan- 
creatitis, followed gradually by ascites, jaundice and 
wasting, should all be familiar to surgeons in this day 
of speed and trauma. 

So effective has been the campaign for seat belts 
that three states have already passed laws requiring 
that front seat belts be installed in all new cars. With 
the increased use of seat belts, this type of case 
might be expected to be seen more frequently. Its 
early recognition, therefore, becomes more import- 
ant. The possible increase in this type of case also 
becomes a cogent argument in favor of the combined 

lap-shoulder belt, which has recendy been stressed 
by Campbell. 2 


1. A case of so-called "seat belt syndrome" has 
been described. 

2. The use of the combined lap-shoulder belt 
rather than the seat belt is urged. 


1. Campbell, H. Role of the safety belt in 19 auto crashes. Bull. 
Amer. Coll. Surg., 40:155, 1955. 

2. Campbell, H. E. And shoulder strap, too. Editorial, Rocky Moun- 
tain Med. J. January, 1963 as quoted in J.A.M.A., April 20, 1963. 

3. Garrett, J. W. and Braunstein P. W. The seat belt syndrome." J. 
Trauma, 2:220-238, 1962. 

4. Kulowski, J. and Rost W. B. Intra-abdominal injury from safety 
belt in auto accident: report of a case. Arch Surg. 73: 970-971, 

5. Tourin, B. and Garrett J. W. A report on safety belts to the 
California legislature. Published by Automotive Crash Injury Re- 
search of Cornell University, New York, Feb. 1960. 

6. Tourin, B. and Garrett J. W. Safety belt effectiveness in rural 
California automobile accidents. Published by Automotive Crash 
Injury Research of Cornell University, New York, Feb. 1960. 

7. Tolins, S. H. Complete severence of the common bile duct due to 
blunt trauma: a case report. Ann. Surg. 149: 61, 1959. 





Chicago — The 1965 Congress on Occupational 
Health, sponsored annually by the American Medi- 
cal Association's Council on Occupational Health, 
will be held concurrently with the annual convention 
of the Indiana State Medical Association. 

The two and one-half day meeting will be held at 
the Murat Temple in Indianapolis, Tuesday through 
Thursday, Oct. 12-14. 

Tuesday afternoon's session will feature a Clinical- 
Pathological Conference moderated by Jan T. Til- 
lisch, MD, member of the Mayo Clinic, Rochester, 
Minn. Participants will be R. Lomax Wells, MD, 
general medical director of the Chesapeake and 
Potomac Telephone Companies, Washington, D. C; 
Lemuel C. McGee, MD, medical director, Hercules 
Powder Company, Wilmington, Del.; Emmett B. 
Lamb, MD, medical director, International Har- 
vester Company, Indianapolis. 

An earlier session on Tuesday will feature A. H. 
Hirschfeld, MD, assistant professor of medicine, 
Wayne University College of Medicine, Detroit, who 

will speak on the subject of disability without disease 
or accident. 

Wednesday sessions have been designed especially 
to interest general practitioners. The opening ses- 
sion on the "Role of the Family Physician in Work- 
men's Compensation" will be moderated by George 
F. Wilkins, MD, medical director, New England 
Telephone and Telegraph Company, Boston. Par- 
ticipating in this symposium will be physicians and 
attorneys experienced in both the legal and medical 
aspects of workmen's compensation cases. 

An afternoon symposium entitled "Role of the 
Family Physician in Employee Health Problems" will 
feature discussions of immunization, emphysema, and 
cardiac problems. Physicians taking part will be 
Richard A. Sutter, Sutter Clinic, St. Louis; O. A. 
Sander, consultant in occupational medicine, Mil- 
waukee; Leon Warshaw, medical director, Para- 
mount Pictures Corp., New York; and Gradie R. 
Rowntree, medical director, Fawcett-Dearing Print- 
ing Company, Louisville. 

Another Wednesday session will feature a talk by 
Leonard E. Himler, MD, Mercywood Hospital, Ann 
Arbor, Mich, on recognition of the emotionally dis- 
turbed employee. 


The joint luncheon on Wednesday will feature a 
presentation of the Physician's Award of the Presi- 
dent's Committee on Employment of the Handi- 
capped. An address will be given by Henry Viscardi, 
Jr., president, Abilities, Inc., Albertson, N. Y. 

A medical-socio-economic conference on Thurs- 
day, moderated by Lemuel C. McGee, MD, will 
feature Joseph Miller, commissioner, Indiana Indus- 
trial Board, Indianapolis; E. H. Bellows, vice presi- 
dent, Olin Mathieson Chemical Corporation, New 
York; and Robert Parker, assistant to the president, 
American Brake Shoe Company, New York. 

Other sessions on Thursday will be devoted to 
discussions of the physician's role in automobile 
safety, preventable occupational dermatoses, per- 
sonal protective equipment for employees, and in- 
dustrial climes. 

A special feature of the meeting will be a 25th 
anniversary Congress on Occupational Health recep- 
tion and dinner on Thursday evening in honor of 
former members of the Council on Occupational 
Health. James H. Sterner, MD, corporate medical 
director, Eastman Kodak Company, Rochester, 
N. Y., will be master of ceremonies. 

For additional information write: Department of 
Occupational Health, American Medical Association, 
535 North Dearborn Street, Chicago, Illinois 60610, 
or to the Indiana State Medical Association, 3935 
North Meridian Street, Indianapolis, Indiana 46208. 


Senior medical students throughout the country 
will soon receive the 1965 edition of Berry Plan 
information bulletin. Its issuance by Dept. of Defense 
marks the 11th anniversary of this system of draft- 
deferment for residency training in exchange for 
subsequent military duty in Army, Navy or Air 
Force. Latest edition for the first time, has a section 
on benefits of Medical Corps careers. — Editor. 


Ingestion of Metrecal may cause an increase in 
laboratory values for protein-bound iodine (PBI) 
and butanol-extr actable iodine. When ordering such 
tests the physician should inquire if the patient is 
utilizing commercial dietaries and to so note on his 
request to the laboratory. If the patient is using 
such a preparation, sufficient time should elapse 
(approximately 30 days) after cessation of the di- 
etary for readjustment and a confirmatory test 
ordered. The source of iodine is probably iodocasein. 
The Metrecal-induced increase in PBI values is ap- 
parently not due to alteration in thyroid function. — 

Steinberg & Leifheit (Galveston, Texas), Texas 
Repts. Biol. & Med. 23: 122 (No. 1), 1965. (From: 
Clin-Alert, May 5, 1965, No. 127.) 


A slight change in the composition of influenza 
vaccine for the 1965-1966 season was announced by 
Dr. Luther L. Terry, Surgeon General of the Public 
Health Service, U. S. Department of Health, Educa- 
tion, and Welfare. 

In addition to the representatives of the four in- 
fluenza virus strains — A, A 1( A 2 , and B — which are 
used in the current vaccine, next season's formula 
will include another A z strain, isolated in Taiwan in 
1964. This strain is closely related to the A 2 strain 
which has been associated with epidemic influenza 
during the past season. 

The licensed influenza vaccine manufacturers have 
been advised by the Service's Division of Biologies 
Standards of the addition of the Taiwan A 2 strain for 
the 1965-66 season. 

Three A 2 influenza strains which were responsible 
for influenza epidemics in various parts of the world 
during 1964 have been under intensive study as pos- 
sible candidates for inclusion in the current vaccine. 
Identified as A 2 /Taiwan/l/64, A 2 /Puerto Rico/1/ 
64, and A 2 /Sydney/2/64, they were evaluated for 
their antigenic properties as well as for suitability for 
commercial production. 

Both clinical and laboratory information indicated 
that of the three candidate strains, the Taiwan/ 1/64 
had the most desirable properties. It showed broader 
coverage than the other two, it had greater anti- 
genicity in animal and clinical tests, and was con- 
sidered suitable for production. 

The laboratory and clinical work was carried out 
by Drs. J. Anthony Morris and Vernon Knight, Na- 
tional Institutes of Health; Dr. Fred Davenport, 
University of Michigan; Dr. Edward Buescher, 
Walter Reed Army Institute of Research; and Dr. 
Joseph Quilligan, of Loma Linda University, Los 
Angeles. After careful consideration of the data, 
the Division of Biologies Standards advised the 
manufacturers to proceed with the manufacture of a 
vaccine in which the A 2 influenza virus strain rep- 
resentation is equally divided between Japan/ 170/ 
62, the current A 2 representative in the vaccine, and 
Taiwan/ 1/64. 

Accordingly the present recommendation for the 
strain composition of the vaccine for the 1965-66 
season is as follows : 

A PR8 100 CCA 

A, Ann Arbor/ 1/57 100 CCA 


A 2 Japan/ 170/62 100 CCA 

A 2 Taiwan/ 1/64 100 CCA 

B Maryland/ 1/59 200 CCA 

"It is clear that we continue to be in a period of 
antigenic change," Dr. Terry said, "and that exam- 
ination and analysis of the strains isolated in this 
country and abroad during the current season, or 
later in the present year, may call for further recom- 
mendations."— USDHEW, Public Health Service, 
Washington, D. C. 


A total of 35,209 nurses were employed full-time 
by national, State, and local public health agencies 
— both official and nonofficial — and by local boards 
of education in January 1964, according to a report 
just issued by the Public Health Service, U. S. De- 
partment of Health, Education, and Welfare. 

The 1964 total represents an increase of 10,000 
over 1950, the Public Health Service said. Most of 
the gain occurred in the number of nurses employed 
by local school boards, which increased their nursing 
staffs from 6,000 to over 13,000 during this period. 

The number of public health nurses who care for 
people in their own homes increased by only 1,700 — 
from 15,900 to 17,600. 

Forty percent of the full-time nurses in public 
health had college degrees in January 1964, and 30 
percent had both a college degree and public health 
preparation approved by the National League for 

The new data are contained in the 59-page report 
"Nurses in Public Health, January 1964," the 22nd 
public health nursing census issued by the Public 
Health Service. The report presents detailed infor- 
mation by State, type of agency, and type of position, 
on the number and educational preparation of nurses 
employed for public health work in the United States, 
Puerto Rico, the Virgin Islands, and Guam. Because 
of the increasing interest in home-care programs, the 
report for the first time includes data on nurses who 
are employed in hospital-based programs for follow- 
up care of patients at home. 

"Nurses in Public Health, January 1964," Public 
Health Service Publication No. 785 Revised, may be 
purchased from the Superintendent of Documents, 
U. S. Government Printing Office, Washington, D. C. 
20402, at 40 cents a copy. Further information on 
the latest census of nurses in public health may be 
obtained from the Division of Nursing, Public Health 
Service, U. S. Department of Health, Education, and 
Welfare, Washington, D. C. 20201. 


"The Medical Department correspondence courses 
NavPers 10504; BIOCHEMISTRY, NavPers 
10503; and SEROLOGY, NavPers 10502 are now 
ready for distribution to eligible regular and reserve 
officer and enlisted personnel of the Armed Forces. 
Applications for these courses should be submitted 
on form NavPers 992, with appropriate change in 
the "To" line, and forwarded via official channels to 
the Commanding Officer, U.S. Naval Medical 
School, National Naval Medical Center, Bethesda, 
Maryland 20014. A description of these courses is 
delineated below: 


POINTS. Provides a concise guide in tropical medi- 
cine for the physician who may be called upon to 
practice in the tropics, and for the physician in tem- 
perate zones who may encounter tropical diseases of 
servicemen and others returning to the United States 
after duty in the tropics. Text: A Manual of Trop- 
ical Medicine, by Hunter, Frye, and Swartzwelder, 
3rd. Edition, 1961. 

This is one of six courses in the Clinical Laboratory 
Procedures series, and deals with the collection of 
bacteriological specimens; identification, classifica- 
tion, and characteristics of bacteria and fungi. Water 
and milk bacteriology, laboratory organization, sero- 
logical testing and antibiotic sensitivity testing are 
also thoroughly covered. Text: Bacteriology and 
Mycology, U.S. Naval Medical School, NavPers 

SIGNMENTS— 6 POINTS. This is one of six 

courses in the Clinical Laboratory Procedures series 
and presents laboratory organization, colorimetric 
and photometric techniques, gasometric analysis, col- 
lection and preservation of specimens, and over 75 
biochemical procedures are covered. In addition, 
there are 20 illustrations of laboratory instruments 
and an extensive bibliography. Text: Biochemistry, 
U.S. Naval Medical School, NavPers 10865-AIII. 

MENTS — 5 POINTS. This is one of the six courses 
in the Clinical Laboratory Procedures series, and 
deals with technique of venipuncture, shipment of 
specimens, handling of glassware, and general tech- 
nique as well as specific instructions for VDRL, Kol- 


mer Complement, Mazzini Microflocculation, Tre- 
ponema Pallidum immobilization, and other tests. 
Text: Serology, U.S. Naval Medical School. 

"Individuals who have previously completed the 
course in Clinical Laboratory Procedures, NavPers 
10994, and Tropical Medicine in the Field, NavPers 
10995 will receive additional credit for completing 
these courses." — Commanding Officer, U.S. Naval 
Medical School, NNMC, Bethesda, Maryland. 


Injection of particulate foreign material into blood 
vessels during angiography obviously should be judi- 
ciously avoided, A source of such material (cotton 
fiber) was found to be the sterile saline solution 
drawn from open containers to irrigate catheters. 
Four cases of embolization resulting from injection 
of contaminated solutions were observed. One oc- 
curred after percutaneous carotid arteriography, and 
three following selective renal arteriography. In the 

latter, gross infarctions were found in the kidneys. 
Solutions used for irrigation should be kept in closed 
bottles and not in open containers where they may 
be easily contaminated with cotton fibers or other 
foreign material, such as glove powder. — Adams 
et al. (Palo Alto, Calif,), Radiol. 84: 678 (Apr.), 
1965. (From: Clin-Alert, May 5, 1965, No. 130.) 


"During the early stages of the present crisis in the 
Dominican Republic, additional medical personnel 
were required on extremely short notice to augment 
units of Fleet Marine Force Atlantic committed to 
the operation. I want to express my sincere ap- 
preciation to both those who worked so diligently to 
fill our requirements and to those who dropped 
whatever they were doing to answer the call. Once 
again the Navy Medical Department has demon- 
strated its readiness to meet any contingency. WELL 

3Jn JWemoriam 

His many friends in the Navy and the medical 
profession were made richer by the life of CAPT 
Malcolm W. Arnold MC USN (Ret) who passed 
away 6 May 1965. Born in Batesville, Mississippi, 
he received his BA degree from Louisiana State Uni- 
versity in 1926 and was graduated from the Johns 
Hopkins Medical School, Baltimore, Md. in 1931. 
He was commissioned a Lieutenant (jg) in the Med- 
ical Corps of the United States Navy on 22 June 
1931 and remained on active duty for almost 34 

During his naval career he served at numerous 
stations including the U. S. Naval Hospital, Guam, 
M. I. and was Chief of the Urology Service at the 
Great Lakes and St. Albans Naval Hospitals. Being 
promoted to the rank of Captain in 1945, he later 
became Commanding Officer of the Naval Medical 
School at the National Naval Medical Center. In 
following years he was Director of the Professional 

Division in the Bureau of Medicine and Surgery 
where he played an important part in expanding the 
Navy's program for residency training of medical 
officers. In his most recent assignment he served as 
Director of the Bureau's Publications Division and 
Editor of the United States Navy Medical News- 
letter, Under his editorship the Newsletter main- 
tained a well regarded reputation for making signifi- 
cant professional medical information available to a 
large circle of Regular and Reserve Medical Depart- 
ment officers. He was a member of the Association 
of Military Surgeons, the North Central Section of 
the American Urological Association, a Fellow of the 
American College of Surgeons, and was certified by 
the American Board of Urology. 

A true gentleman with a kindly manner has been 
lost to the medical profession in which he was a 
respected colleague with the highest ideals of medi- 






E. J. Degnan, Oral Surg, Oral Med. and Oral 
Path. 18(3): 307-311 September 1964. 

The views concerning pre-irradiation exodontia 
expressed in most texts on oral surgery and radiology, 
and which are widely taught and essentially adopted, 
is that teeth should be judiciously extracted prior to 
deep x-ray therapy to the jaws; the reason being to 
reduce the incidence of osteoradionecrosis. However, 
this practice is not universally accepted among some 
leaders in the field of radiology. In fact, Wilder- 
muth, Cantril and their associates believe there is a 
strong possibility that the incidence of osteoradio- 
necrosis increases as a result of pre-irradiation dental 
surgery, and many strongly voice the belief that ex- 
ternal radiation should be started the day the diag- 
nosis of carcinoma is made. 

In an attempt to clarify this situation, a letter was 
sent to 100 leading oral surgeons throughout the 
country requesting answers to these questions : 

A. Do you believe that exodontia (full mouth, 
those in line of radiation therapy, or those teeth 
which are grossly carious) significantly reduces the 
incidence of osteoradionecrosis? 

B. If answer to A is "yes", what is the minimum 
time allowed for the healing process prior to initia- 
tion of radiation therapy? 


Seventy of the 100 polled answered the question- 
naire. Fifty-four felt that pre-irradiation exodontia 
does reduce the incidence of osteoradionecrosis; six 
said it did not; and ten had no opinion. 

Concerning the extent of exodontia prior to ir- 
radiation : 

1. Ten said all the teeth in the oral cavity should 
be extracted. 

2. Thirty-five said, only those in line of radiation. 

3. Eight said, only those with caries and periodon- 
tal disease. 

4. Sixteen felt a combination of 1 and 2. 

5. One said only those teeth interfering with the 
placement of an oral cone. 

The answers to question B — (minimum time al- 
lowed for healing prior to radiation therapy) — 
ranged from no delay to seven days, ten days, six 
weeks, wound completely healed, to indefinite. 

Thus it is obvious that there is a substantial lack 
of agreement concerning the extent of surgery 
deemed necessary as well as the length of time one 
should wait prior to initiating x-ray therapy. 

At the present time there is general belief that pro- 
phylactic exodontia is of value in reducing the in- 
cidence of bone necrosis, but there is no thorough 
and well-substantiated evidence as yet to prove this 
point, at either the research or statistical level. 

The authors conclude that there is great need for 
further work at the research level in the animal lab- 

(Abstracted by: CAPT Seymour Hoffman, DC, 
USN, U. S. Naval Training Center, Great Lakes, 111.) 


B. H. Seidberg, D.D.S. D. Progress. 4(1): 37-42 
October 1963. 

Having been referred to as "the ulcer of the proxi- 
mal end of the alimentary tract", Vincent's infection 
is described as a disease that finds its mark in those 
patients suffering from fatigue, inadequate diets or 
emotional stress. 

Diagnosis may be made clinically on the basis of 
an acute inflammatory reaction of the papillary and 
marginal gingiva, with a punched-out, eroded, crater- 
like destruction of the gingiva and underlying tissues. 
Ulceration starting at the tip of an interdental papilla, 
later involving the marginal gingiva, destroys the 
former and distorts the gingival architecture of the 
latter. An ulcerating grayish-white or greenish-white 
pseudomembrane sloughs away leaving exposed a 
sensitive, bleeding concave depression. 

Other predisposing factors include poor oral hy- 
giene coupled with other local contributing causes. 

Therapy is based upon establishing a favorable 
balance between resistance and infection. Supportive 



treatment in the nature of rest, good nutrition, and 
vitamin supplements, if needed, is a prime considera- 
tion. Treatment of local factors by establishing a 
sound oral hygiene regimen is of vital importance. 
Proper brushing, irrigations with hydrogen peroxide, 
use of gentian violet and antibiotics, if necessary, 
are included in the treatment. Once the disease is 
under control, periodontal treatment, including gin- 
givoplasty and osteoplasty, should be considered. 
(LT B. H. Seidberg, DC, USNR, Boston Naval Ship- 
yard, Boston, Massachusetts, presented the above 
paper before the Tufts University School of Dental 
Medicine on 5 November 1964, in Boston, Massa- 


In 1913 the first naval dental officer was ordered to 
the Marine Corps. Since that time, members of the 
dental corps have provided treatment for the Ma- 
rines during times of war and peace. Many of our 
officers and enlisted personnel have received decora- 
tions for action in combat and others have received 
appropriate recognition for their professional capa- 
bilities both in the field and in garrison. The Navy 
Dental Corps has established a fine record with the 
Marine Corps. This often demanded personal sacri- 

During World War I, two dental officers were dec- 
orated with the Nation's highest award, the Medal of 
Honor. Lieutenant (junior grade) Weeden E. Os- 
borne was the first Naval officer to meet death in the 
land fighting overseas. He was helping to carry the 
wounded to a place of safety when killed. Lieutenant 
(junior grade) Alexander G. Lyle won his Medal of 
Honor for extraordinary heroism and devotion to 

Few engagements took place in World War II 
without active participation of dental personnel serv- 
ing with their units. Proportionately, each contributed 
his share in all the efforts of each campaign. Dental 
Officers and Dental Technicians carried out regularly 
assigned duties, assisted in the sick bays and operat- 
ing rooms, administered supportive therapy, gave 
anesthetics, and aided in identifying the dead. Again, 
during the Korean Conflict our Corps was called 
upon to support the Marine Corps in their usual 
combat environment and did so with distinction. 

Of note is the fact that, among numerous dental 
officers who have been honored for their service to 
the Marine Corps, the present Staff Dental Officer, 
Headquarters, Marine Corps, was awarded the Le- 
gion of Merit with Combat V for his professional, 

military, and administrative contributions during the 
Korean conflict. 

It was during the Korean Conflict that a new con- 
cept in dental support was applied after the Chosin 
Reservoir Operation. In this operation the Marine 
units were extended over a wide area. Providing 
adequate dental care to men in the forward units was 
found to be almost impossible, and little else besides 
emergency treatment was given. Consequently, a 
new concept was considered, in which most of the 
dental personnel were combined in a group and 
established in an area where their services could be 
utilized more effectively. The area chosen was in the 
rear echelon where troops were billeted when their 
units were placed in reserve. This arrangement 
proved to be more efficient than had been expected, 
and resulted in a recommendation to conduct studies 
for a reorganization of the dental services within the 
Fleet Marine Force. The period of study and evalu- 
ation looking toward improved dental support con- 
tinued until late in 1955. Upon completion of the 
studies, dental companies were authorized by the 
Commandant of the Marine Corps. 

Force dental companies were organized to provide 
dental support to Marine Divisions, Marine Aircraft 
Wings, or Force Troops. The companies were de- 
signed to attain maximum utilization of professional 
dental manpower while providing the most effective 
and timely dental support to combat or other Fleet 
Marine Force operations. Dental Companies nor- 
mally do not take an active part in an initial landing 
or in the early phases of a Fleet Marine Force com- 
bat operation. However, detachments of the com- 
panies may be temporarily assigned to medical units 
that land early and assist medical personnel with 
casualty treatment, particularly those involving max- 
illofacial injuries. Maximum dental service is con- 
centrated in appropriate areas after the initial phases 
of the assault, and as required. The organization 
and equipment of companies were designed to permit 
a considerable degree of flexibility and mobility thus 
permitting the companies to operate as a unit, or to 
subdivide into small units. Mobile dental detach- 
ments can be sent to separate or independent Marine 
organizations to provide dental support under all 

A dental company consists of 25 officers, 42 dental 
technicians, and three enlisted Marines. The Com- 
manding Officer of a dental company is charged with 
the responsibility for the operation, security and com- 
bat readiness of his command. This includes train- 
ing in the use of field equipment and all other aspects 


of training which prepares individuals, detachments 
and companies for combat duty. 

Providing dental support to widely scattered Ma- 
rine Corps units presents a real challenge to Naval 
Dental personnel. For instance, a detachment of 
dental officers and dental technicians is supporting 
Marine elements in South Vietnam and will soon be 
field testing new dental equipment. If the tests are 
successful, another step will be accomplished toward 
improved field equipment. 

Dental officers and technicians who have not had 
duty in the field with the Fleet Marine Forces have 
missed a very rewarding and interesting experience 
while serving their country. Some dental officers 
and technicians have actually spent more time with 

the Marine Corps than the Navy. They have learned 
to perform their duties quickly and efficiently in a 
field environment without the conveniences of gar- 
rison-type facilities. In addition to their professional 
responsibilities, they have become proficient in the 
art of self -survival, use of weapons and casualty care. 
Dental personnel who have served with the Fleet 
Marine Forces throughout the years have earned 
prestige, respect and are accepted as members of this 
great organization. 

Dental officers and technicians who want to serve 
with the Fleet Marine Forces should request such 
duty when submitting their next duty preferences. 
(Dental Section, BUMED.) 



The following dental officers of the FIFTH Naval District presented clinics as indicated before the Spring 
Meeting of the Virginia-Tidewater Dental Association, April 9 and 10, 1965 in Norfolk, Virginia: 

CDR A. D. Echols DC USN 

U. S. Naval Dental Clinic, Norfolk, Va. 

CDR R. G. Granger DC USN 

U. S. Naval Dental Clinic, Norfolk, Va. 

CDR R. W. Slater DC USN and 

LCDR R. K. Fenster DC USN 

U. S. Naval Dental Clinic, Norfolk, Va. 

LCDR D. G. Garver DC USN 

U, S. Naval Dental Clinic, Norfolk, Va. 

LCDR C. E. Cunningham DC USN and 

LCDR J. H. Burke DC USN 

U. S. Naval Dental Clinic, Norfolk, Va. 

LT C. B. Smith DC USNR and 

LT W. M. Putman DC USNR 

U. S. Naval Air Station, Oceana, Va. 

CDR R. R. Thomason DC USN and 

LT L. S. Vazzana DC USN 

U. S. Naval Weapons Station, Yorktown, Va. 

Are Your Partial Dentures Showing 

The Use of Occlusal Patterns Cut From Anatomic Acrylic 
Denture Teeth to Develop the Occlusion in an Occluso Re- 
habilitation Case 

Operative's Role in Preventive Dentistry 

Pins-Technique=Success in Large Restorations 

Pneumatization Procedures in the Management of Large 
Periapical Lesions 

Operative Dentistry Utilizing Markley Pins 

Repair of Fractured Anterior Teeth 

The following dental officers of the U. S. Naval Dental Clinic, Long Beach, California, presented table 
clinics as indicated before the Harbor Dental Society Annual Scientific Meeting on 14 April 1965 in Long 
Beach, California: 

LCDR A. D. Heyen DC USN 
LT R. A. Hesby DC USN 

Repair of Fractured Anterior Corners Using Precision 
Stainless Steel Pins 

Acrylic Jacket Technique 



The following dental officers and civilian personnel of the U. S. Naval Training Center, Great Lakes, 
Illinois, presented table clinics as indicated on 1 2 May 1 965 : 

Wisconsin State Dental Society — Milwaukee, Wisconsin 

CAPT T. J. Pape DC USN and 
LCDR B. J. Devos DC USN 

B. L. Lamberts, Ph.D and 
T. S. Meyer, M. S. 

The Third Molar and Its Management 

Separation of Salivary Proteins 

Illinois State Dental Society — Rockford, Illinois 

LCDR H. J. Keene DC USN 
LT T. F. Hafner DC USNR and 
LT D. R. Sheppard DC USNR 

LT A. L. Coykendall DC USN 
I. L. Shklair, Ph.D 

Periodontal Disease in Caries Immune Naval Recruits 
Amalgam Failures 

A Test for the Effectiveness of Rinsing the Mouth After 

C-Reactive Protein and Periodontal Disease 

CAPT W. Naish DC USN, Fourth Naval District Dental Officer and dental officers of the FOURTH 
Naval District hosted the 16th Annual Joint Scientific Meeting of the Philadelphia County Dental Society 
on 21 April 1965 in the U. S. Naval Hospital, Philadelphia, Pennsylvania. CAPT F. J. Kratochvil DC 
USN, U. S. Naval Dental School, Bethesda, Maryland, guest speaker, presented a clinic entitled Peri- 
odontal Considerations for Removable Denture Patients. 

CAPT N. B. Shipley DC USN, Dental Officer, U. S. Naval Auxiliary Air Station, Meridian, Mississippi, 
hosted the Meridian Area Dental Society on 20 April 1965. CDR H. S. Samuels DC USN, Chief of 
Dental Service, U. S. Naval Hospital, Pensacola, Florida, presented an illustrated talk on Oral Pathology. 



On 12 February 1965, the U. S. Naval Photo- 
graphic Center made distribution of this film to all 
ships and stations having a dental facility. The 
dental officer of each facility should have received a 
copy of this film for permanent custody. 

The dental officers who are not aware of the re- 
ceipt of this film are requested to contact their 
command film library and/or their administrative 
officer in order to determine whether or not this film 
has been received. Those dental officers of ships 
and stations who have not received this film are re- 
quested to notify Chief, Bureau of Medicine and 
Surgery, (Code 611 A) at the earliest possible date. 


Residents of Antigo, Wisconsin, are going to re- 
consider their decision of four years ago to end the 

fluoridation of the city's water supply. A survey by 
the State Board of Health has shown that in the 
intervening four years, tooth decay among the city's 
elementary school children has increased as much as 


The study showed that tooth decay had risen 92% 
among kindergarten pupils, 183% among second 
graders and 100% among fourth graders in 1964, 
compared with a similar survey in 1960. 

After publication of the survey results, the city 
council decided to ask residents to vote on whether 
they now favor fluoridation. The vote is scheduled 
April 6. 

Scores of professional persons and civic clubs have 
taken public stands urging a return to fluoridation. 

Editor's Note: 

The referendum on April 6 ratified a return to 
fluoridation— 1824 to 1685. (The AMA News 
8(13): 5 March 29 1965) 









Mouthpiece, Saliva Ejector, Dental 

Strip Assortment, Abrasive Dental, Flint, Coarse Grit, 100s 
Strip Assortment, Abrasive Dental, Flint, Fine Grit, 100s 
Strip Assortment, Abrasive Dental, Flint, Medium Grit, 100s 
Gingival Retraction Cord, Impregnated, Dental, 4 Ply 
Gingival Retraction Cord, Impregnated, Dental, 2 Ply 
Dispenser, Dental Floss, Metal 

Wheel, Abrasive, Diamond, Friction Grip Angle Handpiece, Ball, High 
Speed, 0.065 inch Diameter 

Wheel, Abrasive, Diamond, Friction Grip Angle Handpiece, Flame 
Shaped, High Speed, 0.045 inch Diameter 

Wheel, Abrasive, Diamond, Friction Grip Angle Handpiece, Cylinder, 
High Speed, 0.050" by 0.165" 

Wheel, Abrasive, Diamond, Friction Grip Angle Handpiece, Cylinder, 
High Speed, 0.055" by 0.245" 

Wheel, Abrasive, Diamond, Friction Grip Angle Handpiece, Inverted 
Cone, High Speed, 0.060 inch Diameter 






























LAS VEGAS, NEVADA— Captain Henry H. 
Scofield, DC, USN, Chief of the Dental and Oral 
Pathology Division of the Armed Forces Institute of 
Pathology, Washington, D. C. was elected president 
of the American Academy of Oral Pathology at the 
Academy's 19th annual meeting here recently. 

Captain Scofield succeeded Captain Louis S. Han- 
sen, DC, USN, Head of the Officer Education and 
Training Department, U. S. Naval Dental School, 
National Naval Medical Center, Bethesda, Md. 

Captain Hansen and Captain Scofield presided at 
the annual meeting's two scientific sessions. Dr. 
Robert J. Lukes, former chief of the Hematology 
Branch at the AFIP and now Professor of Pathology 
at the University of Southern California, moderated 
the Academy's annual symposium. The meeting 
was attended by about 200 dentists and physicians. 

Other officers elected by the Academy included: 
President-elect, Dr. Robert J. Gorlin of the Univer- 
sity of Minnesota; Vice President, Dr. Harold R. 


Removable partial dentures 

Oral Pathology 

Oral Surgery 

Oral Roentgenology 

Stanley of the National Institute of Dental Research; 
Secretary-Treasurer, Dr. S. Miles Standish of Indi- 
ana University; and Editor, Dr. Donald A. Kerr of 
the University of Michigan. 

A graduate of Loyola (Chicago) and Georgetown 
Universities, Captain Scofield has been Chief of the 
Dental and Oral Division at the AFIP since 1963. 
He served previously as Head of the Oral Pathology 
Division at the Naval Dental School in Bethesda and 
has had overseas tours of duty in Peiping, China, 
Guam, Japan, Korea and Viet-Nam. 

Captain and Mrs. Scofield and a daughter, Kath- 
leen Ann, reside at 9850 Singleton Drive in Bethesda. 
Another daughter, Mary Jo, is a staff nurse at 
Bon Secour Hospital in Baltimore. 


The following courses and convening dates will be 
available to Reserve Officers 2205, for active duty 
for training during fiscal year 1966 at the U. S. Naval 
Dental School, National Naval Medical Center, Be- 
thesda, Maryland. 

— 27 Sept-1 Oct 1965 

— 4 Oct-8 Oct 1965 

— 18 Oct-22 Oct 1965 

— 25 Oct-29 Oct 1965 

— 10 Jan- 14 Jan 1966 

— 17 Jan-21 Jan 1966 



Complete Dentures 

— 31 Jan-4 Feb 1966 

— 7 Feb- 11 Feb 1966 

— 18 Apr-22 Apr 1966 

— 25 Apr-29 Apr 1966 

— 2 May-6 May 1966 

Fixed Partial Dentures 
Operative Dentistry 
Preventive Dentistry 

NOTE: In the course that runs from 18 April-6 May 1966, the officer may have 
his choice of either Fixed Partial Dentures and Operative Dentistry, or 
Operative Dentistry and Preventive Dentistry. 

Quota Control: COMONE —1 COMFOUR —2 COMEIGHT — 1 

The above listed courses will also be available to 
officers of the U. S. Naval Dental Corps on duty 
assignments east of the Mississippi River. Further 

information will be released through District Dental 
Officers at a later date. 



Taken from the Proceedings of the National Conference on Medical Aspects of 
Driver Safety and Driver Licensing, Nov 16-18, 1964, Palmer House, Chicago. 


The objectives of this workshop are to develop 
guides whose implementation will lead to a decrease 
in the number of deaths and injuries on our highways 
by identification and control of medical factors which 
may impair driving abilities. 


Unfortunately, accident-free driving alone is not an 
adequate measure of performance in the driving 
task. The driving task broadly requires adequate 
physical, mental and emotional capabilities to op- 
erate a conventional vehicle with safety on the high- 
ways of this nation in keeping with usual traffic flow. 

License for this task should be established first as 
a basic, full purpose, or unrestricted license. Addi- 
tional requirements and higher orders of skills are 
necessary for commercial drivers. Restrictions for 
private passenger vehicle operations should be es- 
tablished in accordance with medical abilities re- 
quired for night driving or other circumstances which 
may include specified highway speeds, areas of 
driving, types of roads, or special appliances to meet 
needs of individuals with physical limitations. 


Though many factors contribute to automobile in- 
juries and deaths, it is recognized that medical limita- 
tions constitute a significant factor in driving ability 
and accident production. If alcohol is included as 
a medical problem, then this becomes the most sig- 
nificant factor in driver-produced casualties. 


In many medical areas, control studies with large 
groups of drivers are not available at this time. 
Necessarily, therefore, these appraisals are in con- 
siderable measure provisional guides to be refined 
with the amassing of further medical knowledge and 
statistical data. 

Duration of Medical Limitations 

1 . Short-Term Limitations. 

Acute illnesses and short-term administration of 
drugs may have profound, though transient, effect on 
driving ability. These problems should be met 
through broadened physician awareness, the dissemi- 
nation of information through pharmaceutical chan- 
nels and appropriate patient education through pub- 



lie media. These conditions in no way constitute 
reportable limitations. 

2. Protracted or Chronic Medical Limitations. 

The presence of impairments, deformities, or dis- 
eases which may be chronic, progressive, or inter- 
mittent through periods of months or years constitute 
potential driver limitation calling for medical evalua- 
tion and reporting as agreed upon by involved 

The Role of Treatment, Control or 
Compensatory Devices 

Many medical factors may constitute driver limita- 
tion when not under adequate treatment or control 
The presence of such diseases or abnormalities need 
not bar licensing, but may require periodic medical 
follow-up, reporting or re-examination at the dis- 
cretion of medical authorities and licensing agencies. 
It is inherent in this program that individuals with 
potentially incapacitating medical problems should 
have their driving right safeguarded when adequate 
medical therapy or compensatory devices render 
them safe to operate a motor vehicle. 

The Medical Examiner 

This program acknowledges that physicians neither 
issue driving licenses nor revoke them. It is neither 
the desire nor intention of physicians or medical 
organizations to exercise such responsibilities which 
rightly and appropriately are vested in motor vehicle 
administrators. It is incumbent, however, upon the 
physician to diagnose and classify medical factors 
which may impair driving ability. 

Medical examiners may be classified either as 
initial examiners or as appeal or consultant exam- 
iners. Initial examiners should be physicians, selected 
by individual licensees at their own expense, or desig- 
nated health officers. Out-patient facilities of medical 
schools and related specialists may be called upon in 
appropriate circumstances. Appeal or consultant 
examiners may be asked by licensees or medical au- 
thorities to supply additional information or render 
the basis of initial examination. 

In the presence of non-medical or religious tenants 
bearing on the licensee's concern in medical examina- 
tion, it is recommended that letters of authorization 
from such non-medical authorities be transmitted in 
facilitation of desired examinations. (Permit Con- 
trol Division of the District of Columbia has such a 
letter) . 

Indications for Medical Examinations 

Licensees or applicants may be requested to have 

medical examination under many conditions, and the 
following are suggested circumstances under which 
examination would be indicated: 

1. Following accidents in which the driver indi- 
cates contributing medical factors such as loss of 
consciousness, failure to see collision objects, etc.; 

2. The presence of gross physical impairments at 
the time of application for, or renewal of driver's 
license. Candidates should present themselves in 
person for renewal as well as original license; 

3. Upon written notification by a responsible in- 

4. Reports from physicians as required by law; 

5. Reports from physicians on voluntary basis; 

6. Notification from other states received through 
the National Driver License Register; 

7. Staff physician reports at the time of discharge 
from mental institutions ; 

8. On the basis of previous examinations which 
have revealed medical limitations; 

9. Following multiple accidents or multiple of- 
fenses within prescribed calendar periods; 

10. Licensees placed in the assigned-risk pool for 
reasons other than financial liability or minimal 
licensing age. 

1 1 . School health reports reviewed at the time of 
enrollment in driver training classes. 


Chronologic age itself is not construed as a driver 
limitation. Medical evidence clearly indicates cer- 
tain progressive impairments which accompany the 
aging process ultimately leading to pathologic devia- 
tions from the normal. There is, however, wide- 
spread manifestation of these changes, and therefore, 
examination in the older age groups is recommended 
for cause rather than age per se. Licensing is to be 
based on functional capacities. 


It is recognized that medical limitations may exist 
in all degrees of severity from total incapacitation to 
clinically-insignificant and undetectable levels. 

A calculable degree of severity or cut-off level is 
projected as a deciding line for each of the medical 
factors which may influence driving ability. 

Specific Areas of Medical Limitation 

1. Intelligence. 

The driving task as previously defined necessitates 
the broad understanding of road markings and direc- 
tional signs. Basic intelligence must be adequate to 
perceive and interpret these signs under circum- 



stances of normal traffic flow. The non-trainable 
and non-educable levels of retardation are incompati- 
ble with motor vehicle operation. Applicants mani- 
festing questionable levels of interpretative ability at 
the time of examination should be referred for medi- 
cal evaluation. 

2. Skeletal, Arthritic and Amputation Disabilities. 
Disability must be viewed in terms of the specific 

driving task and may not correlate with employment 
requirements or the ability of the individual to per- 
form manual labor. Acceptable compensation for 
these deficiencies may be achieved by medical ther- 
apy, prosthetic devices or vehicle alterations. In 
private passenger vehicle operation, the minor ampu- 
tation deformities are generally not to be considered 
significant. Major amputation deformities will not 
be considered of significance when the driver is 
properly fitted and skilled in the use of an adequate 
prosthetic device or vehicle modification. Any major 
amputation deficiency precludes commercial driving 
in concurrence with ICC regulations unless a waiver 
has been granted in accord with procedures specified 
in the ICC regulations. Progressive or chronic joint 
diseases constitute driver limitation when creating 
major impairment of skeletal mobility and should be 
reevaluated at periodic intervals by the medical re- 
view board. ( 1 ) Joint diseases which cause pain on 
movement are considered in the same light as those 
causing mechanical limitations. 

3. Neuromuscular Defects. 

These are classified as static impairments (such 
as resulting from cerebral palsy, cerebral vascular 
accidents or following polio-myelitis), progressive 
impairments {such as paralysis agitans or central 
nervous system syphilis), or potentially progressive 
impairments (such as multiple sclerosis and its many 
variations, or myaesthenia gravis). Drivers in the 
latter two classifications should have periodic medical 
re-evaluation and assume some personal responsi- 
bility in contacting medical advisory boards in the 
event of changes in their disease, either due to further 
functional loss or alterations in medical management. 

4. Cardio-Vascular and Renal Dejects. 
Compensated cardio-vascular and renal diseases 

are not driver limitations in private vehicles, but are 
limiting factors in commercial driving. 

a. Angina Pectoris precludes commercial driving, 
but is not significant in private passenger driving 

if the patient is under proper medical care. 

b. Stokes-Adams syndrome, when not accom- 
panied by loss of consciousness or when adequately 
managed by artifical pacemakers, may not constitute 

private passenger vehicle limitations, but precludes 
commercial vehicle operation. 

c. Myocardial infarctions. Adequate rehabilita- 
tion following myocardial infarctions need not pre- 
clude private passenger licensing, but does preclude 
commercial driving except under unusual conditions 
certified by competent cardiologists. 

d. Generalized atherosclerosis and senile Parkin- 
sonism create progressive reduction in reaction time 
and motor responses and may constitute driver limi- 
tation at any time according to the judgment of the 
examining physician. Periodic medical review should 
be instituted on the basis of initial medical examina- 

5. Sensory Deficits. 

Visual impairments are classified in terms of: 

a. Optimally-corrected central acuity at distance; 

b. Horizontal form fields; and 

c. Night vision. 

In private passenger vehicle operation optimally- 
corrected central acuity of less than approximately 
20/40 is unacceptable. 

In commercial driving corrected central acuity of 
20/20 in each eye is required. 

Promptness in acknowledgement of central visual 
acuity is recognized as essential in vehicle operational 

Visual fields are recognized as of particular im- 
portance in intersectional collision. Cumbersome- 
ness of current testing procedures generally precludes 
this type of testing, except on request by the medical 
examiner. Drivers with corrected central acuity at 
the lower limits of acceptability should have visual 
field determinations. 

Similarly, night vision is subject to progressive 
impairment of light sensitivity and glare recovery in 
proportion to advancing age and in some cases calls 
for special examination or license restriction. 

Cumbersomeness and inadequacies of testing vi- 
sion under conditions of partial illumination (mes- 
opic vision) render this testing appropriate only on 
request by the examining physician. 

The loss of serviceable vision from one eye im- 
poses some limitation on driving ability. The sig- 
nificance of monocular visual loss requires further 
medical evaluation. 

A uditory 

Hearing is acknowledged to constitute a relatively- 
minor sensory avenue in vehicle operation, but in the 
presence of gross limitation requires the installation 
of additional outside mirrors. Hearing assumes in- 
creasing importance in association with visual re- 



ductions at the lower limits of acceptability or 
restriction of movement because of joint disease. 

6. Neuropsychiatry . 

Psychiatric disturbances are recognized as signifi- 
cant factors in accident causation, but current prob- 
lems in screening and in differential diagnoses render 
the identification of driver limitations in this area 
extremely difficult. 

Where it is possible, psychiatrists are requested to 
report to the medical board, driver limiting illnesses 
in patients discharged from state or private institu- 

Convulsive States (Altered Levels 
of Consciousness) 

These conditions should be reportable to medical 
authorities for periodic surveillance, but under ade- 
quate treatment and control do not limit private 
vehicle operation. 

Intractable seizure states preclude licensing for all 
types of vehicles. 

7. Endocrine Disease. 

Senile onset diabetes controllable by diet alone 
does not constitute driver limitation and is generally 
of no concern to motor vehicle administrators. 

Diabetes or hypoglycemic states requiring oral or 
parenteral medication should be reported to medical 
authorities for periodic review. If adequate treat- 
ment is maintained, this does not constitute reason 
for withdrawal of private vehicle license, but does 
preclude commercial carrier licenses. 

Juvenile diabetes are characterized by unusual 
severity, difficulties in management and pre-disposi- 
tion to long-term complication, and therefore, closer 
periodic surveillance is required. 

8. Alcoholism. 

Alcoholism is recognized as a major contributing 
factor in traffic accidents and frequently as a symp- 
tom of underlying phychiatric illness. 

Reasonable evidence of chronic alcoholism consti- 
tutes a real driver limitation and grounds for suspen- 
sion of driving privileges until evidence of adequate 
correction is submitted for medical review. 

Blood alcohol levels of .05 per cent constitute 
medical impairment of driving ability and blood 
alcohol levels of .10 per cent indicate intoxication. 

The cooperation of the courts is urged in referring 
suspect problems of alcoholism for medical and psy- 
chiatric evaluation. 

All factors in the above medical evaluations are 
considered as supplemental to requirements of cur- 
rent screening procedures. 

Minor degrees of impairments in several of the 

above may constitute driver limitation just as may 
major impairment in a single area. 

This program expects of the examining physician 
the exercise of sound responsible judgment based on 
individual evaluation. 


Taken from the Proceedings of the President's 

Conference on Occupational Safety, June 23-25, 

1964, Washington, D. C. Presented by Gordon 

S. Siegel, MD of Washington, D, C. 

Population growth, and an aging population, 
changes in social values and systems an "affluent 
society", and a host of other factors are interacting 
to make health services a growth industry — a most 
phenomenal growth industry. Make no mistake, 
health workers are engaged in big business. The 
category of health service workers now ranks seventh 
in the list of major occupational groupings. 

An analysis of 1960 data reveals that 2.6 million 
people were engaged directly in health services, rep- 
resenting 4 percent of the total experienced labor 
force. In the decade 1950-60, the population of the 
United States increased 19 percent — all employment 
increased 1 4 percent — but the number of workers in 
health services increased an amazing 60 percent. 
This growth and its resultant health and safety im- 
pact is reflected in the choice of this subject and 
panel for inclusion in the 1964 President's Confer- 

Health services is not only a big business, it is an 
unusual business. Many of the customary incentives 
to health and safety control in other common enter- 
prises seemingly have been inoperative in the health 
services. There has been little incentive to promote 
occupational health and safety as a means of financial 
loss control and profit stimulation. We find it dif- 
ficult to measure units of production or to quantitate 
efficiency as related to delivery of health services. 
Health service units vary greatly in size, scope, and 
in function. There is a tremendous array ranging 
from the solo practitioners of the healing arts to giant 
hospital corporations, from the one-man research lab- 
oratory to medical research institutes employing 
literally tens of thousands. Disasters highlighting 
and pointing to occupational health and safety prob- 
lems have been relatively rare; those which have 
occurred have frequently been ignored. Manage- 
ment has been deficient. 

Similarly, health workers themselves are often 
characterized by the adage "Familiarity breeds con- 



tempt". It is ironic that workers whose milieu and 
purpose is the promotion of health and alleviation of 
disease often have displayed a callous, sometimes ir- 
rational, attitude toward the inherent health hazards 
in their work. Simplest attempts at injury recogni- 
tion and institution of control measures have been 
ignored or resisted. 

Now, however, we are faced with a giant, growing 
enterprise, one in which the sheer economic burden 
of modern medical care and research dictates at- 
tempts to institute efficient management. The fan- 
tastic associated technology in which health workers 
are enmeshed is beginning to take a visible, increas- 
ing work-related injury and disease toll. Thus, there 
is now belated recognition, and some understandable 
fear, of modern health and safety problems in the 
health services industry. 

Those of us who are more than passingly interested 
in this problem and in developing control measures, 
find few reliable facts and figures to help determine 
accurately the scope and nature of the problem. At- 
tempts to assess meaningful work-injury and illness 
facts and figures are frustrating, for strangely, among 
health workers who pride themselves on the neces- 
sity for maintaining accurate and detailed records, 
little vital occupational health and safety data are 
recorded. Yet, there is no paucity of incidents to 
clearly indicate that there are important unsolved 
health and safety problems. I am sure that my fellow 
panelists will amply discuss specific problem areas 
and experiences which will bear out my conclusions. 

Specific examples are enlightening and focus at- 
tention on the urgency of some current health haz- 
ards to health workers. Who are these health work- 
ers? Some 1.2 million persons are professional and 
technical workers, some 0.8 million are service work- 
ers, an additional 0.4 million are clerical workers, 
and 0.2 million other workers are officials, craftsmen, 
operators, and laborers. 

Many of these people are struggling with the health 
work of mental hygiene and mental illness care. The 
department of mental hygiene of a large State re- 
cently reported on disabling work injuries to its 
15,000 employees over a 1-year period. There were 
1,649 disabling injuries, including 3 fatalities. There 
were 44 fractures, 27 burns, and 21 crushing in- 
juries — this in a "service" occupational group! The 
heaviest U. S. manufacturing industry would never 
accept 1,649 disabling work injuries a year, re- 
sulting in 38,000 man-days lost time, in an employee- 
force of 15,000 workers. 

Health practitioners at all levels are prone to at- 
tack by unexpected — and perhaps lethal — hazards. 

A recent issue of the British Medical Journal editor- 
ialized on "lessons about smallpox". I quote, "In 
the outbreaks here 67 cases occurred with 26 deaths, 
giving a fatality of 39 percent — some indication of 
the lethal nature of smallpox. . . . turning to the 
cases themselves, we first see the serious conse- 
quences of inadequately protected medical and aux- 
iliary staff who may come into contact with smallpox 
at any time in the course of their ordinary duties . . . 
the erratic visitations of smallpox seem to lull us into 
a false sense of security". 

Hospitals have striven mightily to safeguard the 
welfare and safety of their patients. What of their 
employees? The Bureau of Labor Statistics of the 
U. S. Department of Labor undertook an extensive 
and detailed study of the work-injury experience of 
hospital employees based upon records for the year 
1953. This represented a full year's experience for 
approximately 838,000 hospital workers. Strains 
and sprains, hernias, and fractures are usually indic- 
ative of heavy manual handling activities. Special 
studies made by the Bureau in 12 other industries 
showed only one industry, warehousing and storage, 
with a greater proportion of strains and sprains than 
hospital workers. 

Laboratory workers and researchers may be in the 
forefront of danger. At a recent national meeting on 
occupational zoonoses (diseases of animals trans- 
mittable to man), it was reported that there have 
been 1 6 deaths among laboratory and research work- 
ers due to infection with monkey B virus. This dis- 
ease of non-human primates, which generally 
produces a mild illness in the natural host, frequently 
produces a fatal encephalitis in man. Vigorous at- 
tempts are being made to develop a vaccine to pro- 
tect laboratory workers and researchers working 
with monkey colonies. Recent surveys carried out 
by the Division of Occupational Health, unfortu- 
nately, adequately document the lack of understand- 
ing and safety hazards found among laboratory 
personnel. There has been a concomitant lack of 
vigorous management effort to promote health and 
safety. Expert chemists may, and frequently do, 
have poor understanding of the health and safety 
factors and problems associated with their work. 
Rudimentary safety controls, such as the grounding 
of electrical equipment, the availability and enforce- 
ment of the proper use of eye protective equipment, 
instruction in toxicity and appropriate emergency 
first aid, are often inadequate or completely lacking. 
The current technologic revolution has intensified 
and compounded such problems. 



To reiterate: Health work is big business. Large 
numbers of health workers are engaged in a growth 
industry. Both "management" and "labor" in the 
health services have been guilty of neglect of the 
problem of occupational health and safety. The 
growth of health services, and the rapid increase in 
the number of health workers, coupled with the 
economic necessity for efficiency of operation in 
health services are bringing the neglected problems of 
occupational health and safety to attention. Tech- 
nological advance, in addition to its benefits, is all 
too often providing daily deleterious health and safety 
environments for health workers. The health haz- 
ards to health workers, although significant, have 
been dimly perceived and inadequately studied; in- 
dicated programs of occupational health and safety 
control must be instituted. It is my hope that this 
workshop and this Conference can focus national 
attention on the problem. 


James B. Black, Safety Officer, PHS, HEW, 
Washington, D. C. 

A few years ago in an eastern hospital, a physician 
caused hot metal to spew out into nearby nursing 
cribs when he attempted to tighten a leaking safety 
release on an oxygen cylinder with a greasy wrench. 
Contacting oxygen with grease and attempting to ad- 
just a safety release, or for that matter, any fitting 
under high pressure might indicate that training in 
the health industries is almost nonexistent. Training 
is the key to success but it continues to offer a for- 
midable stumbling block for several reasons: Be- 
cause supervisory personnel are more highly educated 
than in most other industries, they feel that any time 
taken to receive environmental control instructions 
would be wasteful; most health agencies do not em- 
pipy safety personnel but of those that do, divided 
authority among such facets as infection control, 
waste disposal, radiation monitoring, sanitation, fire 
prevention, disaster planning, and accident preven- 
tion dissipate the quality of instruction; good train- 
ing is partially based on a knowledgeable instructor, 
but knowledge is difficult to come by in the health 
industry because hazardous incident narrations are 
never readily exchanged between agencies because of 
possible legal implications, notoriety, and because 
patients and citizens would soon lose faith in such 
establishments. Fortunately health workers do read 
and, through the written medium, accelerating prog- 
ress is being made. Many useless statistics are 

gradually being replaced by descriptions of specific 
incidents narrated in pharmaceutical, biological, and 
chemical house organs, State and Federal health, 
industrial hygiene, and hospital newsletters, and in 
separate publications of the AMA, AHA, and the 

Some training should be aimed at imparting spe- 
cific knowledge and some at creating a hazards 
awareness. For example, most health workers would 
be completely surprised to learn that the autoclaving 
of cellulose nitrate centrifuge tubes may cause an ex- 
plosion; that stoppered vials may implode if sub- 
jected to fast exhaust; that ampoules of biological 
materials may explode upon removal from a liquid 
nitrogen refrigerator; that a person could be asphyxi- 
ated if he worked a few seconds too long in a walk- 
in box where dry ice is stored; and that the storage 
of flammable solvents in a domestic refrigerator, the 
distillation of ether, and the disposal of picric acid 
could result in explosions. 

In addition to inadequate training, other manage- 
ment deficiencies exist to further complicate the 
problem of minimizing disability. For the most part, 
health employees work as individuals at nonroutine 
assignments and without physical supervision. For 
example, a technician narrowly missed complete 
blindness moments after he had screwed the lid 
down on a bottle full of leftover chemicals which he 
had gathered together in an attempt to clean up the 

Health workers do not work at a constant site 
where variables are at a minimum, but in places such 
as homes, in swamps, and at meat-packing houses. 
A meat inspector told me about a warning sign he 
had observed in a large storage refrigerator. It read, 
"Use This Axe in Case of Emergency — It Won't Do 
You Any Good But It Will Keep You Warm". How 
many cold boxes like this are equipped with an 
alarm bell and an internal unbolting system? 

Health workers handle people who are at times 
noncooperative and unpredictable. Many nursing 
personnel suffer strains and sprains from lifting or 
adjusting patients who may suddenly shift their 
weight in an unexpected fashion. For example, a 
dentist was struck in the mouth by a psychiatric pa- 
tient because the attendant failed to warn him about 
the patient's possible behavior. 

Health personnel receive supervision from tech- 
nical people who are not themselves closely allied 
enough to the establishment to take interest in the 
total management, such as a visiting physician to one 
hospital patient. For example, a physician discards 
a needle into the waste basket, smokes while apply- 



ing a flammable solvent to his patient, or does simi- 
lar things which are strictly against the hospital rules 
but which cannot be readily controlled by the per- 

Health activities are not subjected enough to in- 
spection by outsiders; partially because health ad- 
ministrators are doing "the best they can" with 
limited public and private funds. Also, because in- 
spections in depth would certainly reveal deficiencies 
on the part of the professional personnel but enough 
public sympathy could be generated to make such 
inspections meaningless. 

The communication channel between scientific and 
administrative personnel is not always clear. For 
example, a baby was burned to death at a non-PHS 
hospital because the heating pad failed. It was old, 
full of pin holes and not rated for wet areas. The 
purchasing people were not told that heating pads 
would be used on patients, to say nothing of helpless 
infants; on the other hand, the nursing staff had been 
rebuked many times for not making equipment last 
a little longer. A death resulted from a typical im- 
passe where technical and nontechnical personnel do 
not always respect each other's particular specialty. 
In other industries where hazardous operations exist, 
there would never be a question of extra money to 
purchase the highest quality equipment and a backup 

Overlaps in various environmental control disci- 
plines tend to create slow progress. Sealing around 
pipes may be desired to prevent noise transmission, 
for vector control, for fire prevention, nuisance, toxic, 
or explosive atmosphere transmission, dry sweepings, 
or contaminated water from floor flushing. Where 
control personnel are trained to view environmental 
deficiencies as a total package, more progress can be 

made. Another example serves to dramatize this dis- 
sipation of effort which, by the way, is not at all 
limited to health industries but is a weakness of all 
safety programs. Sanitation people want plastic refuse 
cans because they're easy to clean; administrators 
want them because they don't make noise; fire people 
don't want them because they will transfer fire to 
adjacent containers; accident-prevention personnel 
want smaller containers with sturdy top rims to pre- 
vent causes of hernias and lacerations and to mini- 
mize possible foot injury. 

More complex instrumentation creates new haz- 
ards which are not well known. Examples include 
the fire and shock hazards of electrophoresis equip- 
ment, ozone created by xenon tube photometry 
equipment, toxic hazards of gas and vapor chromo- 
tography, microwave radiation and sonic vibration 
equipment, and liquid atmosphere applications. 

Scientific personnel are quite often given credit for 
having more knowledge and ability to apply this 
knowledge than they actually possess. Although pro- 
fessional personnel are generally aware of toxic 
chemicals such as mercury or nitric acid, they usually 
do not become alarmed when a thermometer breaks 
in a hot oven or a technician drops a large bottle of 
nitric acid on the floor, although either exposure 
could be lethal. 

Now, how to speed up the breakthrough in health 
industries. First of all, the professional personnel 
must be convinced that a problem exists. Then the 
administrator must be educated to coordinate the 
many disciplines required to produce an effective 
control of the environment, looking upon accidents 
as a single symptom of deficient management. These 
two steps should produce enough light to uncover a 
path to progress. 



John W. Macy, Jr., Chairman U. S. Civil Service Commission 

In the thousands of inspections of agency person- 
nel operations which the Commission has made in 
the past 15 years one finding stands out clearly: the 
caliber of the agency's staff, whether good or bad, 
can be traced directly to the impact of line manage- 
ment decisions of prior years. 

"The quest for quality," when it has been success- 
fully achieved, reflects not so much the excellence 
of the personnel office as the insistence of top 
managers on selecting and training a competent 
staff. True enough, the personnel organization of 
the agency — backed up by recruitment programs, 



tests, and standards of the Civil Service Commission 
— can be of major assistance, but the crucial deci- 
sions are those made by the top man and his man- 
agers all down the line. 

Today's missions and vast responsibilities of Fed- 
eral agencies demand a high degree of staff effective- 
ness. Building the Great Society will require an 
able, dedicated career force, in addition to Presi- 
dentially appointed leaders of vision and talent. 

For its part the Civil Service Commission is under- 
taking a fundamental review of staffing policies and 
operations which affect more than two million posi- 
tions in the competitive civil service. We want to 
insure that our regulations, instructions, and stand- 
ards that govern the filling of these positions meet 
the realities of today's employment conditions. It is 
essential that all departments and agencies having 
competitive positions undertake a similar searching 
review of staffing policies and procedures, and I am 
suggesting such action in personal letters to agency 

Need for Coordination 

One problem area is already apparent to us — the 
need for better coordination between programs for 
recruiting, examining, and selecting new employees 
and programs for reassigning and promoting em- 
ployees already on the rolls. In our regular inspec- 
tions we will emphasize the need for coordination of 
the entire staffing process rather than separate ap- 
proaches to recruitirjg, examining, placement, pro- 
motion, etc. In this way we hope to encourage wider 
use of the principle that jobs should be filled by the 
best placements possible. 

Because of the historical emphasis in the Federal 
merit system on open competitive examinations, the 
program for boards of U. S. civil service examiners 
located in the agencies grew up separately from pro- 
grams for placing and promoting employees within 
the agencies. By emphasizing quality staffing we 
hope to bring these two functions of external and in- 
ternal recruitment into a sounder and closer relation- 

The basic concept of boards of examiners, repre- 
senting a partnership between the Commission and 
experts in the agencies, dates back to the Civil 
Service Act of 1883 and is fully viable today. In 
fact, this partnership is now stronger than it was a 
generation ago, when the Commission attempted to 
employ on its own rolls experts in agriculture, eco- 
nomics, the natural sciences, etc., to plan and con- 
duct examinations in their specialized fields. We 

found that truly expert professionals did not regard 
this type of examining work as a challenging career. 
Today, through a greatly expanded program of 
boards of examiners, we are able to enlist the part- 
time services of acknowledged experts from the 
agencies that will employ the candidates who pass 
the examinations. In this way we can assure our- 
selves that examining standards and procedures and 
the actual rating process will be shaped by persons 
who have full professional competence in the occu- 
pational areas concerned. 

Our inspections emphasize the need to coordinate 
board activities closely with the agency's internal 
staffing programs. In addition, we assist agency 
management in improving all aspects of staffing prac- 
tices. We urge managers not to await the formal 
inspection process but to make their own regular 
reviews of the whole staffing activity of their agencies. 

Merit Promotion 

The Federal Merit Promotion Program, covering 
more than 2 million jobs in the competitive service, 
has now been in effect for 6 years. Its primary goal 
is to assist Federal managers in designing simple, 
effective methods for assuring that promotions will 
be made from among the best qualified employees 
available. The Commission recognized that no one 
system would be equally effective for all agencies, in 
view of vast differences in size, structure, geographi- 
cal dispersion, mission, and occupational character- 
istics. Therefore, agencies were given discretion to 
shape their own promotion programs within broad 
guidelines issued by the Commission, and after con- 
sultation with employee organizations. These guide- 
lines include the following principles : 

1. Broad areas of consideration must be used to 
provide a supply of well qualified candidates for 

2. Qualification standards and evaluation methods 
must be reasonable and valid, and must be ap- 
plied with fairness and equity to all candidates. 

3. Selection must be made from among the best of 
the qualified candidates without discrimination 
among them for any nonmerit reason such as sex, 
race, religion, or politics. 

4. Concurrent consideration should be given to 
qualified individuals outside the agency who are 
known to be available. 

5. Provision must be made for administrative action 
on complaints arising out of promotion proce- 
dures and actions. 

6. The views of employees and employee organiza- 
tions must be obtained in developing promotion 



plans and when making substantive revisions in 
7. Adequate procedures must be developed for 
periodic review of promotion guidelines and 

Our reviews of the new program show that it has 
demonstrated its value to both employees and agency 
management. The program's insistence on compe- 
tition for promotion within wide areas of considera- 
tion and selection on the basis of merit has created 
promotion opportunities where there were none be- 
fore and has led to the selection of competent people 
who would otherwise have been overlooked. 

Several perfecting amendments have been made to 
Commission guidelines and instructions as the result 
of our reviews but no major changes were found 
necessary. Nevertheless we find that some misunder- 
standings about the promotion program still exist 
among managers and employees. 

The following are typical of misunderstandings on 
the part of employees : 

"Why call this a promotion program when agencies 
can still hire people from the outside?" 

In requiring adoption of the new promotion pro- 
gram, the Commission did not infringe on the right 
of the manager to choose the method of filling each 
vacancy. Thus he can decide to fill a vacant job by 
reassignment, transfer from another agency, rein- 
statement of a former Federal employee, probational 
appointment from a civil service examination, or pro- 
motion from within. Our civil service system has 
always provided this type of flexibility — an essential 
feature of merit staffing. 

Qualified persons from outside an organization 
should be given concurrent consideration. Only in 
this way can we have a measure against which to 
judge candidates already in the organization. A Fed- 
eral agency or office is, first of all, a public organiza- 
tion with a responsibility to staff its positions in the 
public interest. Only by preserving its abilty to 
consider and select from among the best of all the 
qualified persons available can management carry 
out this trust effectively. For this reason, a Federal 
office cannot be the private "career preserve" of its 
own employees, nor can management permit the 
stagnating effect of too much inbreeding. This is not 
merit promotion. 

Other respected career systems which are run on 
merit principles have, in recent years, recognized the 
need for "lateral entry" at middle and upper levels; 
for example, the American Foreign Service and the 
British Administrative Class. In the American civil 
service, we have always kept the way open for com- 

petent persons from business, labor, universities, and 
other segments of American life. We need to insure 
that these doors remain open, not slightly ajar. 

Because of their job-related experience, well quali- 
fied employees necessarily enjoy an advantage over 
outsiders in getting many higher level positions and 
a virtual monopoly on them in most areas where 
qualifications unique to Government are required. 
This fact notwithstanding, it is a proper public re- 
sponsibility -to require that agency management re- 
tain the flexibility to consider other citizens where 
they too — through open competition — can meet 
agency needs. What is in the public interest must 
prevail. This is fundamental. 

"The areas of competition for promotion are too 
broad in my agency's plan." 

It is natural for employees in a division or office to 
feel that they should have the inside track when a 
vacancy occurs in that office. Therefore they may 
be concerned when an employee is brought in from 
another division or office of the agency. What they 
overlook is that a broad area of competition, while 
seeming to go against them in this case, may well 
operate in their favor the next time by getting them 
a promotion in another office of the agency. 

The practice of giving real consideration to so- 
called outsiders means greatly enlarged promotion 
opportunities for highly qualified people. Semiauto- 
matic promotion of the less well qualified would 
injure the quality of the public service and the best 
interests of all its employees. From the viewpoint of 
the agency and the general public, it is essential to a 
sound career development plan for employees to 
compete for promotion on a broad interoffice, re- 
gional, or even nationwide scale, depending on the 
type of job. Otherwise promotional opportunities 
are too much a matter of change; one regional office 
may have a high turnover so that every remaining 
employee can progress as fast as his qualifications 
allow, while in another regional office of the same 
agency, better qualified employees may lose oppor- 
tunity to advance. 

The Commission has not attempted to prescribe or 
define areas of competition for promotion purposes, 
since this will necessarily vary with the kinds of 
jobs and the needs of the agency. But the basic 
effort of the whole promotion program is to extend 
these areas beyond the narrower confines used in the 

"More weight should be given to seniority in rank- 
ing employees for promotion." 

Seniority can properly be controlling in such man- 
agement decisions as assigning preferred work shifts, 



lunch hours, parking spaces, vacation periods, etc., 
but the selection of candidates for promotion to 
higher grades is too crucial to the future health of an 
enterprise to be decided on such an automatic basis. 
Seniority as the primary determinant in promotion 
disregards the public interest in the favor of the 
special interests of one employee who has the most 
time in a given office. The employee with long ex- 
perience on the job has a natural advantage if he 
has continued to grow as a result of this experience 
but we all know of employees whose long tenure on 
the job has not increased their effectiveness propor- 
tionately. The criterion of seniority for advancement 
completely ignores factors of potential, initiative, 
drive, and leadership ability which we must encour- 
age and reward if we are to raise productivity in line 
with the commitment of the President and our obli- 
gation to the American people. 

The very nature of our personnel system gives 
ample evidence of the Commission's interest and 
good faith with respect to the needs of long-service 
employees. That system, however, should never be 
so narrow in its promotion principles that it puts a 
premium on how long an employee has been around 
and outweighs an honest appraisal of how far he is 
capable of going. In other words, when management 
promotes an employee, it should give primary con- 
sideration in its selection to its assessment of how 
well the individual will perform the more difficult 
job, not solely to how long he has done a less re- 
sponsible one. This principle is also fundamental. 

"My agency should post notices informing all em- 
ployees of vacancies." 

Posting or circulating notices is certainly one ef- 
fective way of calling promotion opportunities to the 
attention of interested employees. Many Federal 
agencies have adopted such plans after consulting 
with their employees. The advantages of this meth- 
od are obvious and easily understood. It does have 
the weakness that an employee who is absent for a 
while may miss an opportunity to apply. Also, the 
posting requirement may delay filling the job. 

Another method of insuring consideration for all 
employees is a review of employee records by the 
personnel office. This requires, of course, complete 
and current statements of qualifications prepared by 
employees, and some systematic way of coding the 
records so that all eligible employees will come up 
for consideration when a vacancy occurs. A dis- 
advantage of this method is that the employee doesn't 
know every consideration he receives. However, 
there are important advantages. Here, again, the 

employee doesn't have to be constantly alert to apply 
for every possible opportunity for fear of missing one. 

The Commission has not specified which of these 
basic methods agencies must choose, since we believe 
this is a matter to be decided by each agency in the 
light of its own management needs, after appropriate 
consultation with its employees. 

Management also has its share of misunderstand- 
ings about the promotion program. Following are 
three typical comments : 

"The program requires too much paperwork." 

The Commission's guidelines are broad and do not 
specify details or procedures. In an earnest effort to 
do a good job some agencies have developed need- 
lessly elaborate systems. In our inspections of 
agency promotion programs we find more occasions 
to criticize overly complicated plans than overly 
simple ones. We hope through our inspections to 
reduce promotion paperwork wherever possible. We 
urge managers to review their present procedures 

At the same time, we must all recognize that a 
talent search requires some effort, whether it is a 
nationwide contest for high school science students 
or a military or civilian promotion program. 

"When most or all candidates for promotion are 
qualified to fill the vacancy, I can't possibly rank 
them adequately to select the best qualified." 

Ranking large numbers of employees who already 
meet minimum standards for a vacancy can be a 
real problem. Appropriate written tests, records of 
experience and training, interviews, and supervisory 
appraisals all have value when properly used. This 
can become a technical matter, and the manager 
would do well to request advice from his personnel 
staff. The Commission is developing materials to 
help agencies in the evaluation and ranking process. 
But the manager must personally involve himself in 
the process, rather than relying on external formulas, 
by expressing his definition of quality candidates and 
determining the methods that will select them. 

"The same person would have been promoted any- 

This comment sometimes comes from agencies 
which had effective promotion programs before 
1959; in other words, there is nothing new in the 
program for agencies which have always done a 
good promotion job. In other cases, an outstanding 
candidate may loom above all other contenders re- 
gardless of formal procedures. But even in such 
cases the capable manager will want to assure him- 
self, by systematic screening, that the apparently 
logical choice is actually the best qualified. In this 



way the promotion plan provides a way of verifying 
or doublechecking what seems to be an obvious 

These misunderstandings, plus our findings in 
many inspections, highlight the need for better com- 
munication between top management and those who 
operate the promotion program or come under its 
provisions. In our inspections we find that sub- 
stantial numbers of employees have some knowledge 
of the promotion plan but a significant number do 
not. The Federal Merit Promotion Program is re- 
spected most by those who know most about it. 
Practically all the complaints were withdrawn by 
the employees when the promotion procedure was 
fully explained. Of course, in considering criticisms 
of any promotion plan, we must allow for the feel- 
ings of people who are not selected for advancement. 
Understandably there will always be some disappoint- 
ments; therefore, complaints and appeals must be 
sympathetically considered. 

A Commission Action Program 

The action program for quality staffing which the 
Commission is undertaking includes the following 
elements : 

1. The Commission will focus its resources on a 
positive program to achieve quality staffing in 
the Federal service, including a critical review of 
recruitment, examining, staffing, and career de- 
velopment policies and practices. 

2. Future reviews of agency personnel management 
will emphasize quality staffing and will inquire 
how managers are meeting their responsibilities 
in this important area. 

3. We expect to publish periodic reports analyzing 
Federal turnover and accessions, occupation by 
occupation, and projecting requirements for new 
workers several years in advance. This should 
help agency managers as well as the Commission 
staff and placement officials in the educational 

4. We will place increased emphasis on quality 
staffing when conducting training conferences for 
agency personnel. For example, a new course 
has recently been given in Washington to junior 
placement officers and plans are going forward 
to conduct similar training in the field. An ad- 
vanced course for heads of agency placement 
programs is now being planned. 

5 . We will give increased assistance to agency place- 
ment officials through developing better evalua- 
tion and ranking techniques. As we prepare 

new or revised classification and qualification 
standards, we will identify the important factors 
to be considered in evaluating candidates for 
selection and promotion. 
6. The Commission will take action to maintain the 
high quality of Federal personnel officials, since 
they obviously have an essential role to play in 
upgrading the quality of the entire staff. High 
standards for entrance into Government person- 
nel work continue to be needed as well as effec- 
tive career development and training of those 
already on the rolls. 

What the Manager Can Do 

To summarize, the following action steps are sug- 
gested for responsible Federal managers who wish to 
advance the cause of quality staffing in their organi- 
zations : 

1. Hold fast to the concept of filling each vacancy 
with the best possible candidate, whether from 
within the agency or from elsewhere. 

2. Review personnel practices to insure that the 
concept of quality staffing permeates all aspects 
of the program, with due emphasis given to ad- 
vance planning, identification of needs, proper 
relationship of external and internal recruitment, 
and development of promotion ladders and cross- 
training opportunities. 

3. Using the Commission's periodic manpower pro- 
jections as a start, develop agency projections, 
occupation by occupation, as precisely as pos- 

4. Keep employees and employee organizations 
fully informed of staffing practices. 

5. Eliminate unnecessary delays and paperwork in 
placement programs. 

6. Above all, insure that responsible program man- 
agers fully accept their responsibility for person- 
nel management. Let them know that they will 
be evaluated on their ability to do so. Where 
appropriate, encourage them to serve as members 
of boards of examiners, to comment on proposed 
CSC drafts of classification and qualification 
standards, to go on recruiting trips, to comment 
on proposed changes in promotion plans, to 
serve on promotion panels, and to plan and 
participate in training and career development 


Through the initiative and vigorous leadership of 
the President, we now have a white-collar salary scale 



that is reasonably competitive with that of private 
employment. We need to insure that the quality of 
Federal staffing and performance on the job are 
commensurate with these improvements in the Fed- 
eral salary structure. As President Johnson recently 
stated on signing the Government Employees Salary 

Reform Act of 1964, "America's challenges cannot 
be met in this modern world by mediocrity at any 
level, public or private. All through our society we 
must search for brilliance, welcome genius, strive for 
excellence . . ." (From: OIR Newsletter XVI (4): 
5-8, April 1965.) 





PERMIT NO. 1 048 


DCO-- 'DEU*. OP 07E